When I first started therapy, it felt like I could never find the right skills that would help me overcome my anxiety. It always felt like something was missing. It was not until I found a cognitive-behavioral therapist (CBT) who understood that I did not just have social anxiety. There was more. I suffered from trauma, ADHD and autism. Those of us who struggle with more than one mental health disorder (which is called a “co-morbidity” in the mental health profession) struggle with finding the right mix of tools to help with physical and cognitive symptoms. Both trauma and conditions like ADHD or autism can magnify social anxiety symptoms and make them worse. When you are faced with complex combinations of mental health challenges, it becomes even more important to have a large toolbox of coping skills to manage your symptoms.
Know Your Symptoms
Social anxiety, neurodivergence and trauma can result in very difficult and intense physical and mental symptoms. Panic attacks can happen with both trauma and anxiety. Additionally, trauma can present with its own scary “danger” signals. Nightmares, flashbacks, fast heart rate, difficulty breathing, nausea/queasiness, headaches. All these symptoms of anxiety and trauma can be common. This can create a feedback loop wherein our social anxiety worsens, then our trauma and neurodivergence symptoms worsen as well. Therefore, each client needs to find the skills that help calm not just the feelings of anxiety, but the feelings of trauma as well.
Sometimes it can be hard to tell when you are experiencing a symptom. This is particularly true for those who struggle with frequent symptoms or those who experience a high degree of distress. If you’re having a hard time identifying your symptoms, it can be helpful to track your emotional experiences for a time. So you might make a note of the symptom you are having, what was happening right before you started to experience the symptom, the intensity of the experience (low, medium, high) and how long it lasted. By tracking our symptoms over a few days or a couple weeks, we will ultimately have a list of most of the uncomfortable or distressing symptoms we tend to experience. By paying attention and tracking our symptoms, we can know when and where we will need to use our coping skills.
Build a Coping Toolbox
Box Breathing: One of my favorite tools to help slow down your breathing and promote relaxation is a breathing technique called box breathing. You breathe in for 4 seconds, then hold your breath for 4 seconds, breathe out for 4 seconds, then pause for 4 seconds before taking your next breath. Controlled breathing helps activate our body’s ability to calm ourselves down.
The Container Exercise: Another strategy that I have used with myself and my clients, is the mental strategy of imagining a container. This strategy can help give us a brief break from our symptoms. Start by sitting in a quiet place and visualize a secure container like a box, safe or chest. Now, try to visualize putting away distressing memories into the box. Tuck away scary thoughts, feelings, physical sensations, sounds, and smells into the box. Put the distressing social anxiety into this safe place. Temporarily store the trauma flashbacks in the container. Now imagine closing and locking and putting away the container. Mental containers can be a helpful skill when our brain is sending us danger signals and we feel overwhelmed.
Grounding Techniques: Sometimes high anxiety causes us to feel a sense of dissociation from our body or the situation. We might feel as though we are observing ourselves or things might feel unreal. In these cases, using grounding skills can be particularly helpful. A simple way to try out grounding skills and feel more present is to use your five senses. The goal of these exercises is to draw your attention outside of yourself and outside of your mental process. Ask yourself, what do I smell? Maybe you can smell the leftovers from lunch or the smell of the neighbor’s barbecue. Ask yourself, what do I see? Try to specifically take the step of finding different colors in your environment, eg. name everything in your environment that is green or blue. Use your sense of touch to ask, what can I feel? Can you feel the cool air conditioning? Can you feel the weight of gravity on your body? What can you taste? Does your mouth taste slightly sour or can you taste toothpaste from brushing your teeth? Finally, what do you hear? Can you hear kids playing down the street? Can you hear the TV set on in the other room? Using your five senses in this way is an excellent skill to help us feel more grounded and to reduce feelings of dissociation or detachment. The bottom line is that to handle our symptoms, we must build our toolbox with a wide range of skills to calm our nervous system.
There are a huge number of coping skills out there that help people manage uncomfortable or distressing physical and emotional sensations. I’ve highlighted 3 of my favorites. If these work for you, that’s great! But if they don’t, keep looking! We are all unique and everyone needs to find the coping skills that will work best for them.
Working Memory Considerations
Finally, I wanted to highlight a unique challenge that I have seen many clients struggle with when trying to use our coping skills toolbox, and that is working memory. Conditions like ADHD effect the way people can remember and recall information. When panic sets in, either from social anxiety, a traumatic flashback, or even just typical stress, it becomes difficult for our brains to recall information. With conditions like ADHD specifically, it is not enough to just know the skills; we must be able to recall and use them in real-time. This is not always easy when your brain is busy panicking, and your body is experiencing intense physical symptoms. Again, clients will be in better shape if they discover new strategies to help with memory recall.
One way that clients can help themselves recall various coping skills is to have a list of tools to use paired with a list of symptoms. So if you’ve found that using the mental container technique can help when you have distressing memories, make a note in your phone or on a sticky note where you’re likely to see it. If you’ve found that using the five senses grounding technique helps to reduce your sense of detachment or disassociation, then jot it down or set a reminder on your phone so that you remember to use this strategy. Some clients find that taking pictures or screenshots on their phones serves as a helpful reminder. I’ve even seen some clients use the clever technique of creating and memorizing a poem or a jingle to help them recall the tools in their toolbox. Regardless of which tools you chose for your toolbox, remember that successful use of coping skills is like building a muscle: the more you practice, the more repetition you do, the stronger you get.
Conclusion
Living with any of these mental health concerns is difficult and provides unique challenges but experiencing them in combination adds so many different layers to treatment. If you are struggling, finding a good CBT therapist can help move you towards finding a solution. Fortantely, with the right therapist and other support systems in place, clients can navigate these different layers and build a personalized toolbox that will help them learn to cope successfully.
References
Koyuncu A, İnce E, Ertekin E, Tükel R (2019). Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges. Drugs Context, 2019 Apr. 2; 8: 212573.
Lydiard, R B (2001). Social anxiety disorder: comorbidity and its implications. Journal of Clinical Psychiatry, 62, 17-24.